Neonatal Resuscitation Algorithm (NRP)

Newborn-Specific Resuscitation Protocol

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Neonatal Resuscitation Algorithm (NRP)

Key Principle: A-B-C Sequence

Airway → Breathing → Circulation (different from adult BLS)

Most newborns need only routine care

NRP Algorithm Components

Initial Steps

NRP Key Principle

Most newborns need only routine care. Only intervene if needed.

Warm & Dry

  • Radiant warmer: Set to 36.5-37.5°C
  • Dry thoroughly: Remove wet blankets immediately
  • Warm towels: Use pre-warmed towels
  • Prevent heat loss: Cover head with cap
  • Skin-to-skin: If stable, place on mother's chest

Position & Clear Airway

  • Position: Head in neutral position (sniffing position)
  • Suction mouth: Then nose (if needed)
  • Meconium: Only suction if thick and baby not vigorous
  • Stimulation: Gentle rubbing of back or feet
  • Assessment: Breathing, heart rate, color

Assessment

Breathing

  • • Regular respirations
  • • Good chest movement
  • • No retractions
  • • Pink color

Heart Rate

  • • Count for 6 seconds
  • • Multiply by 10
  • • Normal: >100 bpm
  • • Bradycardia: <100 bpm

Color

  • • Pink: Normal
  • • Acrocyanosis: Normal
  • • Central cyanosis: Abnormal
  • • Pale: Concerning

Decision Point

If breathing well, HR >100, and pink: Routine care
If not breathing or HR <100: Begin positive pressure ventilation

Positive Pressure Ventilation

Indications for PPV

Apnea, gasping, or HR <100 bpm despite initial steps

Bag-Mask Ventilation

  • Mask size: Cover nose and mouth, not eyes
  • Position: Head in neutral position
  • Rate: 40-60 breaths per minute
  • Pressure: Start with 20-25 cm H2O
  • Volume: Visible chest rise
  • Duration: 1 second per breath

30-Second Cycles

  • Ventilate for 30 seconds with 100% oxygen
  • Reassess: Breathing, heart rate, color
  • If HR >100 and breathing: Gradually reduce support
  • If HR 60-100: Continue PPV
  • If HR <60: Begin chest compressions

Chest Compressions

  • Indication: HR <60 despite 30 seconds of PPV
  • Technique: Two-thumb encircling hands
  • Position: Lower third of sternum
  • Depth: 1/3 anterior-posterior diameter
  • Rate: 90 compressions per minute
  • Ratio: 3:1 (3 compressions : 1 breath)

Advanced Airway

  • Endotracheal intubation: If PPV ineffective or prolonged
  • Laryngeal mask: Alternative to intubation
  • Tube size: 2.5-4.0 mm based on weight
  • Depth: Weight in kg + 6 cm

Medications

Indications for Medications

HR <60 bpm despite 30 seconds of coordinated PPV and chest compressions

💊 NRP Medications

Epinephrine
0.01-0.03 mg/kg IV/IO (0.1-0.3 mL/kg of 1:10,000)

First-line medication for bradycardia/asystole. Give every 3-5 minutes.

Volume Expansion
10 mL/kg normal saline or O-negative blood

For suspected hypovolemia or blood loss. Give over 5-10 minutes.

Naloxone
0.1 mg/kg IM/IV/SC

For respiratory depression due to maternal narcotics. Not given during resuscitation.

Vascular Access

  • Umbilical vein: Preferred route for epinephrine
  • Intraosseous: Alternative if umbilical access fails
  • Endotracheal: Epinephrine can be given via ETT (higher dose)
  • Peripheral IV: Difficult in newborns, use if available

Medication Timing

  • Epinephrine: Every 3-5 minutes during resuscitation
  • Volume: Once if hypovolemia suspected
  • Reassessment: After each medication dose
  • Discontinuation: When HR >60 and rising

NRP Key Principles

  • Most newborns need only routine care
  • A-B-C sequence (different from adult BLS)
  • 30-second cycles of intervention and reassessment
  • Epinephrine for HR <60 despite adequate ventilation
  • Volume expansion for suspected hypovolemia
  • Call for help early if resuscitation needed

Reference Information

Source: American Academy of Pediatrics (AAP) and American Heart Association (AHA)

Guidelines: Textbook of Neonatal Resuscitation, 8th Edition

Note: NRP certification requires both cognitive and skills testing every 2 years.